Acne is the single most common skin disease in America. Despite being common, there is a wide range of misconceptions and myths regarding the causes and treatment of acne. Acne is best known by comedones (blackheads and whiteheads), small red bumps (papules) and pimples (pustules). In the worst state, nodulocystic acne, deep boils and cysts form, which can lead to severe scarring. Traditionally, acne originally presented during the hormonally turbulent teenage years; yet adult-onset acne is becoming more common. Whereas teenage acne often appears in the T-zone of the face (the skin over the forehead and nose), adult acne is often linked to hormonal imbalances, most often occurring along the jawline and chin. ​ Acne lesions, especially cysts and nodules, can be painful. Acne in all forms and all stages often substantially impacts a patients’ self-image and has known links with depression. ​ While there is an ongoing debate on the exact cause of acne, the prevailing view in dermatology involves a combination of bacterial overgrowth, overactive sebaceous or oil glands, and abnormal function of the pilosebaceous unit and hair follicles. In many patients, diet, emotional stress, and hormones often lead to worsening or flare-ups of their acne symptoms. ​ There are many highly effective topical and oral medications in managing acne, the longest lasting and most aggressive being isotretinoin, commonly known as “Accutane”. Several acne treatments can be combined with chemical peels or laser and light-based treatments to maximize results. Some patients choose to combine office-based procedures with their topical regimen, so as to minimize side effects from oral medications.

One of the most common reasons for a referral to Dermatology is a rash that fails to respond to therapies attempted by a Primary Care Provider (PCP). As specialists, our Providers are there to assist both the patient and PCP in diagnosing and controlling rashes. ​ Some rashes may be related to an allergic reaction (such as poison oak or nickel), while others are closely linked to irritation from excessive dryness. In every instance, it is important to know the underlying cause of the rash (diagnosis) in order to ensure the proper treatment is prescribed. Sometimes the wrong medication simply results in no therapeutic effect; in other cases, the wrong medication can cause severe worsening of the rash. ​ Rashes run a wide gamut of “base” causes such as: Infectious (tinea corporis, aka ringworm; shingles; measles; hand, foot, mouth disease) Autoimmune (lupus, psoriasis) Allergic (atopic dermatitis, contact dermatitis)

Actinic keratoses (AK) are precancerous skin lesions due to chronic, prolonged sun exposure. Classically, AKs are considered to be an “egg” (baby) form of Squamous Cell Carcinoma. New research is further demonstrating the importance of properly treating these lesions as a disease state over the body and not just as isolated lesions. When present, patients describe AKs as rough, scaly, sometimes red, flat sand-paper feeling growths. If untreated, these lesions may progress to non-melanoma skin cancer (typically squamous cell carcinoma). Early intervention can halt and help “unwind the hands of time” in the progression of the disease, as well as making the skin appear more healthy and youthful. ​ While traditionally each individual lesion was treated with liquid nitrogen, the infamous “freezing” or “burning”, newer evidence is guiding modern clinicians to more effective and long lasting therapeutic options. ​ Photodynamic Therapy (often referred to as “light”, “blue light” or “PDT”), is an office based procedure with long lasting suppression of actinic keratosis lesions. PDT is minimally painful, non-invasive, and requires little effort or discomfort on the part of the patient. ​ Another very effective therapy is topical medications best described as “skin chemotherapy” using medications such as Zyclara, Efudex, or 5-flourauracil. These medications are applied by the patient 1-2 times per day for four to six weeks. While very effective, many patients using topical agents report significant pain (often times described as 7-9 out of 10 pain), redness, and a negative appearance due to the inflammation of the medication applied area. Use of topical medications for AKs is best performed when patients are educated and followed closely during their therapeutic course.

“Cancer” is never a word to be taken lightly; it is important for patients to remember that skin cancer occurs more often than all other cancers combined. The Non-Melanoma skin cancers (NMSC), such as Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), are far more common than Melanoma. Basal Cell is the single most common cancer in the United States with over 3.5 million cases occurring each year. Many patients visit their Dermatology provider after developing a new skin-colored or shiny bump, or a pimple that won’t go away. Often times, patients will also describe “easy bleeding” or “it never heals”. In advanced stages, a Basal Cell will begin to eat away at the skin (ulcerate) as it extends to the deeper skin structures. ​ Squamous cell, in contrast, is classically described as a rough, red, scaly patch that never heals. Some patients describe Squamous Cell lesions as being tender. While Basal Cell and Squamous Cell are rarely deadly, they can invade local skin and deeper tissues, resulting in significant disfigurement or spread to other regions (typically Squamous Cell) when left untreated for significant lengths of time (many years). ​ The treatment for NMSC’s are most often a simple excision with your Dermatology provider. For cancers that are greater risk, or that occur in cosmetically or functionally sensitive areas (such as near an eye or over the nose), Mohs micrographic surgery is the treatment of choice recommended by the American Academy of Dermatology. ​ Melanoma is far less common than Basal and Squamous Cell cancers, but may be deadly. Over the last 20 years, the incidence of melanoma has risen dramatically, particularly in women younger than 40. When melanoma is caught in the early stages, the cure rate approaches 100%. Sadly, when melanoma is not detected, once it has already spread from the skin (metastasized), the results can be devastating. Our Providers firmly believe in the importance of avid sun protection, self-examinations and an annual examination by a dermatology provider. Our Providers perform thorough total body skin exams (TBSE) utilizing dermoscopy and arm our patients with information to best protect themselves and lower their melanoma risk factors. Ultimately, dermatology is an art; we customize your treatment recommendations based on the cancer type, location, functionality of the treatment (how a treatment affects you) and its cosmetic outcome (how it will look). ​ Remember: sunlight damages the skin. Overtime, this damage leads to premature sagging, wrinkling, dulling, freckling, and increased roughness. Think of leather left too long in the sun; it dries, cracks, and deforms, losing its smooth texture and becoming brittle. Skin tags, pre-cancers, and even skin cancer are directly and proportionally connected to cumulative sun exposure over the course of your life.

The appearance of sunspots are very common as we age. Sunspots or lentigines are discrete, flat brown lesions in areas that have had significant sun exposure – typically the face, backs of hands, upper chest, and forearms. To help minimize your risk of developing sunspots, we strongly recommend the daily use of a broad-spectrum sunscreen. The American Academy of Dermatology and the American Cancer Society recommend a minimum of SPF 30 applied regularly, every 90 minutes to achieve the best protection. To treat cosmetically concerning sunspots, multiple prescription and over the counter agents are available to lighten (i.e., bleach) the lesions. For patients desiring complete removal, certain laser types will often result in full resolution of the lesion. While sunspots are not in and of themselves dangerous, the number and severity are an indirect marker showing the extent of a patient’s sunburn or sun exposure over their life. Be safe, protect your skin from the sun

Rosacea is a common condition typically in Caucasians after the age of 40 which is characterized by flushing or redness with or without pimples, predominantly over the face. Many rosacea patients tend to have sensitive skin, and often describe stinging, tingling or burning sensations, especially on exposure to certain chemicals, products, or sunlight. As this sensitivity and flushing worsens over time, small blood vessels (telangiectases) develop in the prominent regions of the nose and cheeks. In other patients, prolonged pimples and bumps (papules) result in scarring of the cartilage structure of the nose creating a “cauliflower” appearance known as Rhinophyma. Rhinophyma can not only disfigure the nose and patient’s self-image, but result in significant discomfort. Many medications can greatly diminish papules and pimples in most patients, though the redness and blood vessels can be just as concerning and are less affected by medications. For more permanent, lasting resolution of redness and flushing, laser or light therapy can often help a patient maximize their goals of therapy

Birthmarks can be present at birth or develop shortly after in the first few months of life. There are two major types of birthmarks, vascular or pigmented lesions. Vascular birthmarks, such as hemangiomas and port wine stains, are often red in color and either flat or bulbous in appearance. While hemangiomas typically go away in time, port wine stains tend to darken and thicken over time, making distinction between these two lesion types important. Pigmented birthmarks such as café-au-lait spots, Nevus of Ota and Becker’s nevus can sometimes be improved with laser treatments. In certain instances surgical excision for a congenital mole (nevi) is sometimes appropriate; if there is doubt, have the lesion evaluated by your dermatology professional

Melasma, known also as “the mask of pregnancy” is best known as patchy dark lesions (hyperpigmented patches) on the face. Classically, melasma is most frequently seen in patients during periods of hormonal changes and/or significant sun exposure. Oral contraceptives and pregnancy are known to exacerbate this condition. Ultraviolet A radiation (UVA) typically has a direct role in the worsening of melasma. For patients at risk for melasma, or with a history of hyperpigmentation, avid sun protection is essential to both the prevention and treatment of melasma. Treatment of melasma is by topical agents (over the counter and prescription), chemical peels, and some laser and light treatments to achieve optimal results

Photodynamic therapy (PDT) utilizes a photosensitizing agent (aminolevulinic acid or ALA) and a light source (Blu U) in order to treat a wide range of skin conditions ranging from inflammatory acne and sebaceous hyperplasia to precancerous lesions (actinic keratoses). ​ For our PDT protocol treating Actinic Keratoses, ALA is applied to the skin and allowed to incubate 90 – 200 minutes, depending on the treatment site. During incubation, the ALA is selectively absorbed by precancerous cells and by the bacteria that inhabits the skin and can cause acne. Once absorbed within those cells, a photochemical reaction occurs converting ALA into protoporphyrin IX, a light sensitive agent. Now that the target cells have “time bombs” inside primed for activation by light, the Blu U light source is applied to the treatment area for 20 minutes, activating the medication. ​ While our patients experience minimal discomfort and achieve amazing results with our PDT protocol, it is very important to conduct strict light avoidance for 36 to 48 hours following treatment. Many patients will note a mild, sunburn-like reaction lasting for two to four days, the length of medication incubation time.

Our Providers all have their primary interest in the prevention, diagnosis and treatment of skin cancer. To better ensure the best results of your total body skin exam (TBSE), we ask that you please remove all of your make-up as well as any nail polish. Your Provider will check you from head-to-toe, utilizing a tool called a dermatoscope to better visualize your individual lesions; our Staff will ask you to disrobe, but you may choose to keep on undergarments, if you prefer. We avise all patients that while a choice not to disrobe fully, that does mean our Providers cannot inspect all of the skin on your body. Additionally, please note that if you remove undergarments for your exam, it is clinic policy for a chaperone to be present during the portions of the exam in which breasts and/or genitalia are exposed. If any Provider finds a lesion of concern during your exam that warrants further evaluation, your Provider may recommend a tissue biopsy. To help ensure each patient has the full time allotted for his or her exam without excessive waiting, biopsies are scheduled at follow-up appointments.

Skin cancers and aesthetics are not the entirety of dermatology, nor is it the limit of our Providers’ capabilities. While benign, multiple types of growths in or on the skin and soft tissues can be aesthetically displeasing, painful, or cause decreased quality of life. ​ These include: Cysts Lipomas Giant comedos These masses are frequent reasons for patients seeking dermatologic care and are easily addressed. We ask patients to note that minor surgeries for these lesions require preparation of both staff and resources, and are not performed same day.

Vascular lesions can be congenital (at birth or near birth) or acquired (senile angioma). There are multiple, mild therapies (hyfrcation) to laser and light sources that are very effective at diminishing or altogether eliminating these lesions, which include hemangiomas, capillary vascular malformations, spider angiomas, broken blood vessels and scars, among others. Virtually all of the vascular lesion removal procedures are well tolerated and almost always performed without any anesthesia and virtually no downtime or post-procedural discomfort. Some patients may note post-treatment swelling or transient darkening of the lesion(s), however this is less common and resolves typically within two to four days.